More information of a technical nature has come to light concerning  the ditching of the Pel-Air air ambulance off Norfolk Island in November 2009 that supports claims that CASA failed to properly regulate the operator and that the ATSB left out crucial considerations in its investigation of the crash.

Plane Talking isn’t able to determine the validity of the information provided but the avoidance by the ATSB of any discussion of these issues in its release of a report white-washing Pel-Air is as damning as the CASA special audit that found more than 20 serious deficiencies in Pel-Air operations immediately after the accident.

The new information follows the disclosure that Pel-Air Westwinds were prohibited from using a band of fuel efficient altitudes along the route of flight that ditched at Norfolk Island in bad weather after a flight from Apia because they had not been upgraded to RVSM or reduced vertical separation minima as discussed in this earlier report.

Pilots have now told Plane Talking that Pel-Air pilots had been conditioned to not even think about using Noumea as a diversion airport for medical flights in the south west Pacific because the company hadn’t brought them up to the European flight standards imposed on users of the main airport, and then, when it did, had failed to train its pilots to operate to those standards.

Westwinds are required to carry TCAS 2 and GPWS according to the European authorities (the JAA) and their regulations (the JARs) because they have the capacity to be configured for more than 9 passengers.

New Caledonia is a statut particulier  of France and applies the JARs to its aviation judisdiction.

Apparently, after multiple warnings from the New Caledonian authorities and after two very hostile aircraft inspections from JAA inspectors (one of which happened to the pilot Dominic James) Pel-Air was banned from operating into New Caledonia until the Westwinds were fixed.

After six plus months being kept away finally VH-NGA (the aircraft involved in the Norfolk Island incident) was modified as the only compliant Westwind at Pel-Air.

Pel-Air then wrote to the New Caledonian authorities and said everything was fixed and approval was subsequently given for VH-NGA to return to New Caledonia.

The only problem was the pilots (including Dominic James) apparently weren’t told that they could return, nor were they trained to use the equipment, nor were the company procedures, policies or checklists modified to reflect the new equipment in NGA.

The problem for Pel-Air was that the new equipment is not legal until the pilots are trained (which they weren’t) and therefore Pel-Air had no right telling the New Caledonian authorities that everything was fixed – which was untrue. Pel-Air was still not compliant with the JARs.

If, in an emergency, the PIC [pilot in command] had to divert to New Caledonia, he would have, but in the minds of the Pel-Air Westwind pilots, Noumea was still a no go destination.

Another pilot raised weather reporting and fuel calculation issues, and queries the competency and scope of the Pel-Air investigation.

I am a Qantas pilot and have been reading the ATSB report of the Pel-Air Norfolk Island accident. From my own reading and conversations with fellow professionals, I have become deeply concerned about the accuracy of information presented as “fact” in the report.

Reading the ATSB report, one of the systemic issues that has been missed and a possible error in detail in the report is the part where the ATSB takes issue with the Captain not asking if any amended TAFs  [terminal area or aerodrome forecasts] had been issued for Norfolk Island. This seems like a stupid statement as, if it hadn’t been brought to his attention that an amended TAF had been issued, why would he ask for it? TAFs are issued at routine intervals. Amended TAFs are only issued if something fundamental has changed in the weather and are issued ad hoc, therefore, unless someone lets you know one has been issued, you would never know. The ATSB report then goes on to say that “Nadi ATC did not, and was not required by any international agreement to, proactively provide the 0803 amended Norfolk Island TAF to the flight crew”. Why is this not a “finding” of the report then?

If a TAF is amended and it fundamentally impacts the safety of an aircraft in flight, why wouldn’t it be a requirement to let the Captain know about it? This seems insane! If this is true, the laws need changing and therefore it is a systemic problem and should have been a finding.

That being said, I am not convinced it is true. In the Air Services Australia Aeronautical Information Publication (AIP), section GEN 3.3, paras 2.5.1, 2.5.4 and 2.5.5 seem to indicate that ATC should be providing pilots with flight information services about the existence of non-routine meteorological reports affecting the safety of relevant aircraft. My reading of these paragraphs lead me to believe the either the ATSB is wrong and Nadi was definitely obliged to inform the Captain of the amended TAF so that he could have diverted to a suitable alternate! I believe this is a crucial issue that has been missed by the ATSB. As a pilot with Qantas, it has also struck me as odd that the ATSB has made a lot of noise about the Captains fuel planning and suggestions of what he could/couldn’t have done with varying fuel load options and yet they haven’t included any numbers i.e. where are their calculations?

The reason this has struck me as odd is that some of the comments they have made about depressurised fuel loads don’t match up with my experience at Qantas and I would like to take a look at how they have calculated it to see if the ATSB hasn’t made an error. I will give you an example.

In Qantas jet operations, we have depressurisation decision points calculated for us pre-flight (by the way, right/wrong, safe/unsafe, these are only a preflight requirement… airborne you can burn into these fuels even if it means your decision point would no longer be valid). As the depressurised fuels do not require a variable reserve and two-engine fuel does, nearly always the depressurised fuel required for a flight is actually less than what would be required legally for two engines. My point is, ATSB has said if depressurised fuel had been calculated, the Captain would have had MORE fuel on board than he carried. This hardly ever seems to be the case in my experience and on the odd occasion it is required, it isn’t usually a significant amount. Considering the Pel-Air Captain had enough fuel on board to not only meet his legal two-engine requirements, but also shoot four approaches before ditching (with fuel still remaining), I find the ATSB assertions about fuel planning and options available less than compelling without data to back it up. I have spoken to friends on other fleets and other airlines to me, and I am not the only one who read this part of the report and was left wondering if the ATSB had cocked up their fuel calculations. We’d all be interested to see them. Another thing I find puzzling is that it is not a finding of the report that had the FO [first officer] been at flight planning, she may have been able to act as a hand-brake to the Captain leaving if indeed errors had been made. The FO, by company SOP, was not included in the flight planning. It seemed important enough to the ATSB to mention that Pel-Air has changed this policy, but not important enough to mention it in the preamble or the findings. The scary bit is that this practice was not Pel-Air specific. I have spoken to Qantas, Virgin and Jetstar pilots who started their RPT careers from Skippers, Network Aviation, Qantas Link etc and they have all indicated at their former employers, when acting as FOs, they would be sent to preflight the aircraft while the Captain did the flight planning. One final question I think needs answering is, why did the crew decide to continue? The ATSB report mentions that they didn’t think they could make Noumea, so they continued on. The report doesn’t answer the question as to why they came to this conclusion. I am assuming they just didn’t do this on a whim. Did they calculate a PNR [point of no return]? Were they past any PNR they may have calculated? If they had calculated a PNR (even if it was wrongly calculated) and they were past it, then it wouldn’t just be a case of them being unsure they couldn’t make Noumea, to them it would have been they had no option but to continue. I am sure I have heard somewhere in the media at the time of the prang or on Four Corners, somewhere, that the Captain had calculated a PNR and they had passed it when they finally became aware that the weather had not only gone below alternate minima, it had now gone below landing minima.

Pilots make decisions for reasons and the ATSB has failed to explain what the Captain’s reasoning was. If he had calculated a PNR, where is the data? If he had calculated a PNR, did he use the PNR examples in the Pel-Air manuals? This is vital information missing from the report as the ATSB has made several claims in their report of where they feel real PNRs existed and when decisions could have been made but weren’t.

I’m not for a minute suggesting that maybe the crew couldn’t have been more proactive, but if this report is supposed to explain to aviators why decisions were made that lead to an accident, then where are the explanations? Where are the details? Where are the pilots calculations and where are the ATSBs own calculations? I agree with your conclusion, that the ATSB and CASA seemed to have played the man on this one and the report, as it stands is toiler paper! If they are going to play the man, they could at least show the evidence to support their play. As it stands, playing the man without providing any supporting evidence at all makes me wonder what they are hiding (beyond the CASA adverse findings on Pel-Air that 4 Corners exposed!).

At Qantas we have ALL the systems in place that Pel-Air was lacking. We have a stringent fuel policy that includes decision points for depressurisation, ETOPS and single engine operations. We have a flight planning department that prepares our plans, weather, NOTAMS and makes all calculations for us. We are flight followed and the company lets us know if amended weathers are issued that will adversely affect our flight. Our operations department operates 24/7 and is available for us on the SAT phones they give us. At the end of the day, we are only the final layer of defense in that we check all these other factors before we depart. The Pel-Air audit found them lacking in all these respects.

Without any of these layers available to him, the Pel-Air Captain was the only defense. At Qantas, a lot of holes in a lot of layers of Swiss cheese have to line up for mistakes of this magnitude to happen; at Pel-Air it seems that there was only one layer, the Captain. While he made mistakes, he seems to be the only one being held accountable by CASA and the ATSB.

These disclosures and comments are among a growing folder of matters that at a technical as well as general level undermine the credibility of the supposedly independent air safety investigator.

An unedited video of the chief commissioner of the ATSB Martin Dolan taking 18 minutes to insist that Pel-Air wasn’t in breach of the conditions CASA found that it had been in breach of,  and attempting to justify the report’s focus on the pilot who was carrying out the his duties according to the standards for which Pel-Air was responsible, has been archived on the ABC TV 4 Corners site, together with the once secret CASA special audit of Pel-Air, and an uncut interview with the head of safety at CASA, John McCormick.

The performances of the ATSB and CASA in relation to Pel-Air, and previous safety incidents involving Jetstar, are clear evidence of a break-down in the quality and transparency of the public administration of air safety in Australia.

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